Everyone knows that physicians are chronically evasive and uncommunicative
when it comes to death and dying, so how can I argue otherwise?

Yet to view our failures in the care of the terminally ill and
dying solely as products of physician attitudes misses, I believe,
the larger context in which physicians practice, a context in
which clear communication about death and dying is often poorly
supported.

Physicians practice in a highly competitive climate in which
expectations are often set unrealistically high and the physician
who delivers bad news may be seen as negative and defeatist. Our
genuine success stories may serve only to intensify the pain and
confusion that patients and families face when death happens.
For instance, a patient with incurable lung cancer might, thanks
to advances in treatment, be given an extra good year. But at
the end of that year the physician may be asked: Why couldn't
you cure me, or send me to someone who would?

Even in cases in which patients seem to understand that a cure
is not possible they often change their minds about treatment.
Recently, a patient of mine, an 88-year-old woman with an advanced
intestinal cancer expressed the wish not to pursue further treatment
and go home to die. The next day, when bleeding recurred, her
son called to ask if she could be re-admitted to the hospital.
This all-too-human response underscores the difficulties we all
face in dealing with death and dying. Who among us can be coolly
rational about death? Good physicians do listen to their patients'
wishes, yet in the case of death, the difficulties often lie beyond
the scope of even the best listener.

Claudia Davis Fegan, M.D.

While physicians confront death on a regular basis, we are not
unlike ordinary people in our general aversion to discuss with
patients their impending deaths. There are several reasons for
this.

First of all, to discuss death and dying we have to be at peace
with ourselves. We have to have accepted our own mortality and
have reached some conclusions about our own lives and deaths.
We have to have confronted our own potential to die and have made
decisions about how we would deal with that.

Secondly, it is difficult to not feel some sense of failure with
the death of any patient. Most of us are not good at discussing
our failures. To discuss with a patient her anticipated death
is to accept that we will be unsuccessful in our attempt to preserve
life and to begin to plan for failure.

Physicians typically avoid or curtail these conversations because
they are awkward and painful. These conversations require skills
that are not acquired in medical schools. Medical school cultivate
intelligent, active, innovative skills. Patient listening and
acceptance of the fact that there are not solutions or answers
to every question are not cultivated attributes.

Often, physicians fail to listen to patients' wishes about dying
because it is painful to do so and no physician easily accepts
helplessness. Are we so different from those we serve?

Alan B. Astrow, M.D. is Associate Chief of Hematology and Oncology at St. Vincents
Hospital and Medical Center in New York City. He is also Assistant
Professor of Clinical Medicine at New York Medical College.

Claudia Davis Fegan, M.D., has spent her entire career in medicine devoted to one defining
precept, that quality health care in America is a right -- not
a privilege. Dr. Fegan is president of the medical staff at Michael
Reese Hospital in Chicago, where she is an attending physician
in internal medicine.